Best Practices For SUD Prior Authorization & Care Coordination

Best Practices for SUD PriorAuthorization& Care Coordination0920.MM.P.PP

DisclosuresPlanning Committee Disclosure During the planning stages of this activity, all planning committee membershave declared there are no financial interest/arrangement or affiliation withthe organization that could be perceived as a real or apparent conflict ofinterest in the context of the subject of this -Risha RatliffNo Relationship with acommercial entityAnthemNo resolution neededKristi CarneyNo Relationship with acommercial entityCareSourceNo resolution neededStacy WatsonHolli MahoneyNo Relationship with acommercial entityMDwiseNo resolution neededMargaret RichardsonNo Relationship with acommercial entityMHSNo resolution needed

FSSA Bulletin re: SUD The State issued Bulletin BT201906 in February 2019 outlining the required PA forms

Prior Authorization forms re: SUD

Prior Authorization forms re: SUD

Prior Authorization forms re: SUD

Best Practice for sending a Prior AuthorizationAnthem: Providers may call Anthem to request prior authorization for medical and behavioral healthservices using the following phone numbers: Hoosier Healthwise: 1-866-408-6132 HIP: 1-844-533-1995 Hoosier Care Connect: 1-844-284-1798Fax physical health clinical information for all Anthem members to: Physical health inpatient: 1-888-209-7838 Physical health outpatient: 1-866-406-2803 Fax behavioral health clinical information for all Anthem members to: Behavioral health inpatient: 1-877-434-7578 Behavioral health outpatient: 1-866-877-5229 Web Portal: ICR is available using www.availity.com or throughhttps://mediproviders.anthem.com/inAnthem does not do live clinical reviews

Best Practice for sending a Prior AuthorizationMHS: Fax #: 844-288-2591 Call for live review: 877-647-4848 Web Portal: https://provider.mhsindiana.comCareSource: Fax #: 937-487-1664 IMD Fax #: 937-487-0688 Web Portal: https://Caresource.com (follow prompts to provider portal)CareSource does not do live clinical reviews

Best Practice for sending a Prior AuthorizationMDWise: HIP: Outpatient fax number: 866-613-1642 Inpatient fax number: 866-613-1631 HHW: Inpatient and outpatient fax number: 888-465-5581

The “Do’s” for Prior AuthorizationDo Complete the SUD PA request form in its entirety. Send all listed documentation with the PA form. Send documentation that supports the 6 dimensions of ASAM. Send the most current clinicals; documentation from the last 24-72 hours. Send a summary of why the specific level of care is being requested. Why is this level of service necessary? Why can’t the member be treated at a lower level of care? Send withdrawal assessment scores (COW/CIWA). Make sure the diagnosis matches the service being requested. Send progress in treatment and adjustments to treatment plan when submittingconcurrent PA. Submit a complete and detailed initial assessment, not just check boxes and add theinformation that lead to the checking of the box

Treatment options beyond Acute Inpatient Care Clinical Best Practices indicate that Acute Inpatient Care is not the preferred level ofcare for Opiate detox. We encourage all Providers to work collaboratively with our Case Management andUtilization Management teams to discuss alternative treatment options. We want toensure our members are receiving the correct level of care at the correct time. Alternatives to consider: Outpatient treatment (including Medication Assisted Treatment MAT) Intensive Outpatient Programming (IOP) Partial Hospitalization Programming (PHP) Residential Treatment Programming (RTC)

What is Case Management at an MCE?Case Management encompasses all aspects of a member’s healthcare. Coordinating a member’s medical and behavioral healthcare. Assisting members with securing transportation to/from medical and behavioral healthappointments. Providing education re: disease states and medication adherence. Explaining each member’s healthcare benefits. Providing information re: community resources. Providing crisis management to members. Collaborating with each member’s providers

Managing high risk/high need members For members who have an inpatient admission, Case Managers begin intervening assoon as they are notified of the event. Outreach is made to the hospital social worker, discharge planner & family prior todischarge to coordinate follow up appointments. Notification of admission is sent to the member’s PMP and the identified behavioral healthprovider within five (5) days of admission. *Written consent from the member is requiredwhen their admission is related to substance abuse. Written consent is NOT needed formental health treatment (IC 16-39-2-6(a)). Please get a signed ROI at admission. Once discharge occurs, a call is placed to the member, parent or guardian within 48 hoursand a reminder is given about follow up appointments. The member is then enrolled in case management for a minimum of 90 days.

What a Provider can expect from an MCE Support! Each Case Manager is available to assist in managing the care of the member. Communication! Case Managers call providers re: admissions, readmissions, follow upappointments, and ongoing treatment. Information! Case Managers have access to a member’s healthcare profile which includes ERvisits, medication adherence, medical & behavioral health services, care gaps, andfuture risk scores.

What the MCE needs from the Facilities Communication! Case Managers need to speak with facility discharge planners and/or social workersshortly after the member’s admission re: the discharge plan which should includefollow up appointments, medications, barriers and overall care of the member. Discharge Summaries! Case Managers need discharge summaries, immediately after discharge, thatinclude diagnoses, medications, follow up appointments and other pertinentinformation. Scheduled Follow-up Care! Members discharging from an inpatient admission need to be seen within 7 days ofdischarge with a master level clinician or higher.

Contact UsAnthem:CareSource:La-Risha Ratliff, LMHC, LCACKristi Carney, MSW, LSW, CCMManager Behavioral Health ServicesDirector of Behavioral i Mahoney, LMHCMargaret Richardson, LCSWBehavioral Health SpecialistDirector of Behavioral argaret.e.Richardson@mhsindiana.com

Best Practice for sending a Prior Authorization Anthem: Providers may call Anthem to request prior authorization for medical and behavioral health services using the following phone numbers: Hoosier Healthwise: 1-866-408-6132 HIP: 1-844-533-1995 Hoosier Care Connect: 1-844-284-1798 Fax physical health clinical information for all Anthem members to: